Provider Demographics
NPI:1962447193
Name:BROUSARD, KELLY (SLP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:BROUSARD
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:DOHERTY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:SLP
Mailing Address - Street 1:5325 E AVE NW
Mailing Address - Street 2:
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52405-3245
Mailing Address - Country:US
Mailing Address - Phone:319-390-3013
Mailing Address - Fax:
Practice Address - Street 1:402 10TH ST SE
Practice Address - Street 2:SUITE 700
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52403-2435
Practice Address - Country:US
Practice Address - Phone:319-365-9439
Practice Address - Fax:319-365-9368
Is Sole Proprietor?:No
Enumeration Date:2006-06-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA01534235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist